Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity

Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity Hindawi Publishing Corporation Sarcoma Volume 2013, Article ID 925413, 6 pages http://dx.doi.org/10.1155/2013/925413 Clinical Study Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity Luis A. Aponte-Tinao, Miguel A. Ayerza, D. Luis Muscolo, and German L. Farfalli Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, 1199 Buenos Aires, Argentina Correspondence should be addressed to Luis A. Aponte-Tinao; luis.aponte@hospitalitaliano.org.ar Received 9 October 2012; Revised 26 December 2012; Accepted 18 January 2013 Academic Editor: Andreas Leithner Copyright © 2013 Luis A. Aponte-Tinao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions aeft r excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. K aplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. eTh function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at vfi e years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at vfi e years and 54% at ten years. eTh limb salvage rate was 98% at vfi e and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. eTh best functional score was observed in the intercalary humeral allograft. 1. Introduction the na fi l functional score compared to the anatomical site and the type of the reconstruction. Excisions of a bone tumor in the upper extremity may result in a large residual osseous defect and the loss of periarticular 2. Patients and Methods so-ft tissue stabilizers of the shoulder [ 1–10], elbow [11, 12], or wrist [13–15] with potentially deleterious effects on both From January 1990 to December 2008, we performed a function and viability of the limb. For these locations, there consecutive series of 72 patients with a musculoskeletal are different reconstructions options including prosthetic tumor from the upper limb who underwent reconstruction devices [3, 5–7], biological constructs either with autograsft with a massive allogra.ft Two patients were excluded due to a [5, 6]orallograsft [ 1–15], or the combination of allograft with lack of adequate followup data, leaving 70 cases for analysis. prosthesis [7–11]. Of the 70 reconstructions, 38 were osteoarticular allo- Reconstruction with a massive allograft is preferred in grafts, 23 were allogra-p ft rosthetic composites (APC), and 9 ourservice duetothe possibilityofobtaining supporting were humeral intercalary allografts. Of the 38 osteoarticular mechanical loads and the ability to attach host ligaments and reconstructions, 21 were of the proximal humerus (Figure 1), muscles to the grafts. 16 were of the distal radius (Figure 4), andone of thedistal eTh purposeofthisstudy wastoinvestigate thesurvival humerus. Of the 23 allograft-prosthetic composites, 16 were of allograft reconstructions in the medium to long term, to proximal humeral reconstructions (Figure 2), and 7 were determine factors associated with their failure, and to analyze elbow reconstructions (Figure 3). 2 Sarcoma Figure 1: Anteroposterior radiograph of an osteoarticular allograft Figure 3: Anteroposterior radiograph of an APC of the elbow aer ft of the proximal humerus aer ft 5 years of reconstruction. resection of the proximal ulna. Figure 2: Anteroposterior radiograph of an APC of the proximal Figure 4: Anteroposterior radiograph 16 years aer ft distal radius humerus showing adequate union of the junction. osteoarticular reconstruction. Although degenerative changes are evident, the patient is asymptomatic with excellent function. Demographic data, diagnosis, site of the neoplasm, oper- ations performed, surgical complications, outcomes after surgery, date of last followup evaluation, and local recurrence 1 month aer ft the operation, we obtained plain radiographs were reviewed for all patients. at every visit. We performed functional evaluation using the There were 38 men and 32 women in the study group. eTh revised 30-point functional classification system established mean age at presentation was 32 years (range 4–71 years). by the MSTS [16], which assessed pain, function, emotional eTh most common indication for reconstruction was chon- acceptance, hand positioning, dexterity, and lifting ability. drosarcoma in 18 patients, followed by osteosarcoma in 15, Each variable was assessed on a 5-point scale. Function giant cell tumors in 15, metastasis in 6, Ewing sarcoma in was compared according the anatomical site and the type 5, chondroblastoma in 2, and others types of tumors in the of reconstruction performed. Surgical complications were remaining 9 patients. eTh mean duration of followup was 5 defined according to the Clavien-Dindo classification [ 17] years for patients who survived the original disease (range 1– that separates complications in vfi e grades: Grade I, any 20 years). deviation from the normal postoperative course without the Postoperatively, patients were seen at 1 week, 2 weeks, 1 need for pharmacologic treatment or surgical, endoscopic, month, 2 months, 3 months, and then every 3 months there- and radiographic interventions, with acceptable therapeutic after until 2 years, after which we met annually. Beginning regimens including drugs, such as antiemetics, antipyretics, Sarcoma 3 1 1 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0 0 0 50 100 150 200 250 0 50 100 150 200 250 Months of followup Months of followup Survival function Survival function Censored Censored Figure 5: Allograft survival. Figure 6: Articular surface survival. analgesics, diuretics, electrolytes, and physiotherapy; Grade infections, 5 fractures, 5 resorptions, and 3 nonunions. How- II, complication requiring pharmacologic treatment with ever, only in 16 patients (23%) the allograft was removed (4 drugs other than those allowed for Grade I complications; local recurrences, 5 resorptions, 2 infections, and 5 fractures) Grade III, complication requiring surgical, endoscopic, or (Table 1). In 6 patients the allograft was not removed (3 local radiographic intervention; Grade IV, life-threatening compli- recurrencesinsoft tissueand the3nonunions). cation; and Grade V, death of a patient. We analyzed only Seven patients had local recurrences. Three recurrences Grades III, IV, and V complications in this series. were in the soft tissue and were resected with wide margins; in We considered an allograft to have failed when it was these three cases the reconstructions were not revised, so the removed through either a revision procedure or an amputa- allograft reconstruction was not affected. In four patients the tion, and in osteoarticular reconstructions, we considered a allograft was compromised by the local recurrence. In these jointtohavefailedwhenthe allograft wasnot removed, but fourcasesthegraftwasremovedwiththelocalrecurrenceand symptomatic degeneration of the joint was present at the last only two of them were reconstructed. One was reconstructed followup. with a new allograft (distal radius) and the other with a proximal humerus endoprosthesis. eTh remaining two eTh ratesofsurvivalofthe allogra,t ft he limb,and the patients were treated with a resection arthroplasty and with joint surface were estimated with the use of the Kaplan-Meier an amputation (both of them located in the humerus). method, starting on the date of the operation and ending on the date of removal, amputation, or the latest followup. Two patients had an acute deep infection, in which Cox regression analysis was done to determine whether age, theallograftwas removed, andatemporarycementspacer gender, diagnosis, type, and site of the reconstructions were with antibiotics was implanted. After 6 weeks of intravenous independent prognostic factors. eTh log-rank test was used antibiotics and another 6 weeks of oral antibiotics, we reim- to compare the survivorship curves. A𝑃 value of<0.05 was planted another allograft in one patient (wrist arthrodesis), considered to be significant. and the other patient was reconstructed with proximal humeral prosthesis. Five patients sueff r an allograft fracture, and all occurred 3. Results in proximal humeral osteoarticular reconstructions. All pa- Allograft survival ( Figure 5)atfive yearswas 79%(CI95%: tients required a second operation, including a second allo- 68%–90%) and 69% (CI95%: 55%–83%) at ten years for graft reconstruction with an APC in 3 patients, a second failurefromany causeasthe endpoint (Figure 1). The limb osteoarticular allograft in one, and a cement spacer in the survival rate was 98% at five and 10 years (CI95%: 94%– remaining patient. 100%). Five patients had allograft resorptions, all of them We identified 22 patients with complications requiring a occurred after an elbow reconstruction (four APCs and one second surgery (32%), including 7 local recurrences, two deep osteoarticular allograft). Of the failed elbow reconstructions, Cumulative survival Cumulative survival 4 Sarcoma Table 1: Allograft complications according the different types of reconstructions. Reconstruction Local recurrence Infection Fracture Resorption Nonunion Total (%) PHOA 2 — 5 — — 33% PHAPC 1 1 — — 2 25% HIA 1 — — — — 11% ER 1 — — 5 — 75% DROA 2 1 — — 1 25% PHOA: proximal humerus osteoarticular allogra;ft PHAPC: proximal humerus allograft prosthetic composite, HIA: humeral intercalary allogra;ft ER: e lbow reconstructions; DROA: distal radius osteoarticular allograft. Table 2: Mean MSTS functional results comparison of different types of reconstructions. Reconstruction Pain Function Emotional acceptance Hand positioning Dexterity Lifting ability Total PHOA 4 3 4 3 5 4 23 PHAPC 4 4 5 3 5 4 25 HIA 5 5 5 5 5 5 30 ER 3 4 4 4 5 4 24 DROA 4 4 5 5 5 5 28 PHOA: proximal humerus osteoarticular allogra;ft PHAPC: proximal humerus allograft prosthetic composite, HIA: humeral intercalary allogra;ft ER: e lbow reconstructions; DROA: distal radius osteoarticular allograft. two were converted to an elbow endoprosthesis, two had a the anatomic location of the reconstructions. Despite these resection arthroplasty, and one had a cement spacer. limitations, we believe that this series is one of the largest eTh three patients who underwent nonunion were treated series reported in the literature, and our results may provide with autologous bone graft and a new plate, without revision some trends in the treatment of massive bone defects in the of the reconstruction. upper limb. The articular surface survival ( Figure 6)ofthe group Regarding anatomical site, most publications are related of patients treated with an osteoarticular allograft was 90% to the proximal humerus. Osteoarticular allografts are used (CI95%: 79%–100%) at vfi e years and 54% (CI95%: 39%–69%) less frequently than in the lower extremity, but there are at ten years (Figure 2). All symptomatic articular deteriora- reports regarding this type of reconstruction in the proxi- tions occurred in the proximal humeral reconstructions, and mal humerus. Although some authors reported satisfactory none of them required revision because of this event. results with osteoarticular allograsft of the proximal humerus The only independent prognostic factors that were found [1] and survival rates of 78% at five years [ 2], recent reports to be significant on Cox regression analysis, with revision for suggest that better or at least similar results are obtained with any cause as the end point, were the gender of the patient allograft prosthesis composite and endoprosthesis recon- (more frequent in males:𝑃=0.02 ). structions regarding reconstruction survival and complica- For the patients who retained the reconstruction (54 tions [3–8]. Peabody [4] report that due to functional limita- cases), the mean MSTS functional score at last followup was tions as well as an extremely high rate of complications, they 26 of 30 (83%, range 18–30). eTh best mean functional score do not use osteoarticular allograsft to replace the proximal was observed in the intercalary humeral allograft group. aspect of the humerus. However, in a recent report [7]that (mean 30: 100%). The worst functional score was observed in analyzed 38 reconstructions of the proximal humerus the proximal humeral osteoarticular allograft group (23 points, endoprosthetic group presented the smallest complication range18–26), andthislower scorewas mainly related rate of 21%, compared to 40% in the allograft prosthesis com- with patients who had a significant articular deterioration positeand62%intheosteoarticularallograftgroup.However, (Table 2). in another report that analyzed 45 patients [5] reconstructed aer ft tumor resection of the proximal humerus they found that all limb-salvage procedures for the proximal humerus 4. Discussion were satisfactory for long-term survival, but none of the 26 disease-free surviving patients was able to abduct their In comparison with the lower extremity, there is relatively shoulder more than 90 , and only vfi e could achieve active paucity literature reporting survival and clinical results of abductionofmorethan30 .Thesurvivalratewas 83%for allograft reconstructionsaeft rexcisionofabone tumorofthe endoprosthesis, 79% in clavicula prohumero, and 75% in upper extremity. We include in this report all reconstructions osteoarticular allograft [ 5]. done in the upper extremity done in our unit. Reconstructions with APC in the proximal humerus eTh re aresomelimitations to this study. Thisisaretro- avoid problems of endoprosthesis or osteoarticular allograsft spective study with a relatively low number of patients and used alone [8–10]. In our series the higher amount of fractures followup. In addition, there are many variables related to Sarcoma 5 occurred at shoulder reconstructions with osteoarticular [2] H. DeGroot, D. Donati, M. D. Di Liddo, E. Gozzi, and M. Mercuri, “eTh use of cement in osteoarticular allografts for allografts, and these complications could be avoided with an proximal humeral bone tumors,” Clinical Orthopaedics and APC. In recent reports [8, 10] there are not differences regard- Related Research,no. 427, pp.190–197,2004. ing complications or survival with other methods. [3] M.I.O’Connor, F. H. Sim, andE.Y.S.Chao, “Limbsalvage for Although, reports on elbow reconstructions [11, 12]show- neoplasms of the shoulder girdle: intermediate reconstructive ed satisfactory functional outcome and survival, both reports and functional results,” Journal of Bone and Joint Surgery—Series included trauma and tumor patients. In our series, we found A, vol. 78, no. 12, pp. 1872–1888, 1996. high complication rate (75%) and a mean functional score of [4] P. J. Getty and T. D. Peabody, “Complications and functional 24 points. Five of seven patients’ present allograft resorption, outcomes of reconstruction with an osteoarticular allograft and this complication was noted in previous report [12]. aer ft intra-articular resection of the proximal aspect of the hum- All distal radius reconstructions in this series were osteo- erus,” Journal of Bone and Joint Surgery—Series A,vol.81, no.8, articular allografts. In our series we found low complication pp. 1138–1146, 1999. rate (19%) and high functional score (28 points). Similar [5] R.W.Rod ¨ l, G. Gosheger, C. Gebert, N. Lindner, T. Ozaki, and W. results are found in the literature [13–15]; however, all series Winkelmann, “Reconstruction of the proximal humerus aeft r include a high percent of patients with benign tumors (GCT). wide resection of tumours,” Journal of Bone and Joint Surgery— This could lead to less damage of soft-tissue structures and Series B,vol.84, no.7,pp. 1004–1008, 2002. better survival of thepatient andreconstruction. Although [6] Q. Yang, J. Li, Z. Yang, X. Li, and Z. Li, “Limb sparing surgery degenerative changes are reported [14], these are usually for bone tumours of the shoulder girdle: the oncological and asymptomatic (Figure 4). functional results,” International Orthopaedics,vol.34, no.6,pp. The lower complication rate and the best mean functional 869–875, 2010. scorewereobservedinthe intercalaryhumerus allograft [7] M. A. J. van de Sande, P. D. Dijkstra, and A. H. M. Taminiau, group. Van Isacker et al. [18] report in a series of forearm “Proximal humerus reconstruction aer ft tumour resection: allograft similar results, they found that intercalary allograft biological versus endoprosthetic reconstruction,” International had fewer complications than osteoarticular allografts, and Orthopaedics, vol. 35, no. 9, pp. 1375–1380, 2011. they had a better functional MSTS score. [8] A. Abdeen, B. H. Hoang, E. A. Athanasian, C. D. Morris, P. J. Boland, and J. H. Healey, “Allograft-prosthesis composite re- construction of the proximal part of the humerus. Functional 5. Summary outcome and survivorship,” Journal of Bone and Joint Surgery— Series A,vol.91, no.10, pp.2406–2415,2009. This study showed that allograft reconstruction aeft r a [9] A.W.Black,R.M.Szabo,and R. M. Titelman,“Treatment tumor resection of the upper limb may be durable, with a of malignant tumors of the proximal humerus with allograft- 69% survival rate at ten years. Despite the 32% incidence of prosthesis composite reconstruction,” Journal of Shoulder and complications, only 16 patients (23%) required an allograft Elbow Surgery,vol.16, no.5,pp. 525–533, 2007. removal and were considered as failures. We conclude that [10] P. Ruggieri, A. F. Mavrogenis, G. Guerra, and M. Mercuri, “Pre- articular deterioration and fracture were the most frequent liminary results aer ft reconstruction of bony defects of the prox- mode of failure in shoulder reconstructions and allograft imal humerus with an allograft-resurfacing composite,” Journal resorption in elbow reconstructions. eTh humeral intercalary of Bone and Joint Surgery—Series B,vol.93, no.8,pp. 1098–1103, allograsft had the lesser complication rate and the best functional score. [11] F. D. Kharrazi, B. T. Busfield, D. S. Khorshad, F. J. Hornicek, and H. J. Mankin, “Osteoarticular and total elbow allograft Conflict of Interests reconstruction with severe bone loss,” Clinical Orthopaedics and Related Research,vol.466,no. 1, pp.205–209,2008. Each author certifies that he or she has no commercial asso- [12] K. L. Weber, P. P. Lin, and A. W. Yasko, “Complex segmental ciations (e.g., consultancies, stock ownership, equity interest, elbow reconstruction aeft r tumor resection,” Clinical Ortho- patent/licensing arrangements, etc.) that might pose a con- paedics and Related Research,no. 415, pp.31–44,2003. flict of interests in connection with the submitted paper. [13] M. S. Kocher, M. C. Gebhardt, and H. J. Mankin, “Reconstru- ction of the distal aspect of the radius with use of an osteoartic- ular allograft aeft r excision of a skeletal tumor,” Journal of Bone Disclosure and Joint Surgery—Series A, vol. 80, no. 3, pp. 407–419, 1998. Each author certiefi s that his institution has approved the [14] G. Bianchi, D. Donati, E. L. Staals, and M. Mercuri, “Osteoar- reporting of this study, and that all investigations were con- ticular allograft reconstruction of the distal radius aer ft bone ducted in conformity with ethical principles of research. tumour resection,” Journal of Hand Surgery,vol.30, no.4,pp. 369–373, 2005. [15] R. M. Szabo, K. A. Anderson, and J. L. Chen, “Functional out- References come of en bloc excision and osteoarticular allograft replace- ment with the Sauve-Kapandji procedure for Campanacci grade [1] M. C. Gebhardt, Y. F. Roth, and H. J. Mankin, “Osteoarticular 3 giant-cell tumor of the distal radius,” Journal of Hand Surgery, allografts for reconstruction in the proximal part of the hu- vol. 31, no. 8, pp. 1340–1348, 2006. merus aeft r excision of a musculoskeletal tumor,” Journal of Bone and Joint Surgery—Series A,vol.72, no.3,pp. 334–345, [16] W. F. Enneking, W. Dunham, M. C. Gebhardt, M. Malawar, 1990. and D. J. Pritchard, “A system for the functional evaluation of 6 Sarcoma reconstructive procedures aer ft surgical treatment of tumors of the musculoskeletal system,” Clinical Orthopaedics and Related Research, no. 286, pp. 241–246, 1993. [17] P. A. Clavien, J. Barkun, M. L. De Oliveira et al., “eTh clavien- dindo classification of surgical complications: vfi e-year experi- ence,” Annals of Surgery,vol.250,no. 2, pp.187–196,2009. [18] T. van Isacker, O. Barbier, A. Traore, O. Cornu, F. Mazzeo, and C. Delloye, “Forearm reconstruction with bone allograft following tumor excision: a series of 10 patients with a mean follow-up of 10 years,” Orthopaedics and Traumatology,vol.97, no.8,pp. 793–799, 2011. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Sarcoma Hindawi Publishing Corporation

Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity

Loading next page...
 
/lp/hindawi-publishing-corporation/allograft-reconstruction-for-the-treatment-of-musculoskeletal-tumors-x60JL89aVh

References (22)

Publisher
Hindawi Publishing Corporation
Copyright
Copyright © 2013 Luis A. Aponte-Tinao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
ISSN
1357-714X
eISSN
1369-1643
DOI
10.1155/2013/925413
Publisher site
See Article on Publisher Site

Abstract

Hindawi Publishing Corporation Sarcoma Volume 2013, Article ID 925413, 6 pages http://dx.doi.org/10.1155/2013/925413 Clinical Study Allograft Reconstruction for the Treatment of Musculoskeletal Tumors of the Upper Extremity Luis A. Aponte-Tinao, Miguel A. Ayerza, D. Luis Muscolo, and German L. Farfalli Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, 1199 Buenos Aires, Argentina Correspondence should be addressed to Luis A. Aponte-Tinao; luis.aponte@hospitalitaliano.org.ar Received 9 October 2012; Revised 26 December 2012; Accepted 18 January 2013 Academic Editor: Andreas Leithner Copyright © 2013 Luis A. Aponte-Tinao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In comparison with the lower extremity, there is relatively paucity literature reporting survival and clinical results of allograft reconstructions aeft r excision of a bone tumor of the upper extremity. We analyze the survival of allograft reconstructions in the upper extremity and analyze the final functional score according to anatomical site and type of reconstruction. A consecutive series of 70 allograft reconstruction in the upper limb with a mean followup of 5 years was analyzed, 38 osteoarticular allografts, 24 allograft-prosthetic composites, and 8 intercalary allografts. K aplan-Meier survival analysis of the allografts was performed, with implant revision for any cause and amputation used as the end points. eTh function evaluation was performed using MSTS functional score. Sixteen patients (23%) had revision surgery for 5 factures, 2 infections, 5 allograft resorptions, and 2 local recurrences. Allograft survival at vfi e years was 79% and 69% at ten years. In the group of patients treated with an osteoarticular allograft the articular surface survival was 90% at vfi e years and 54% at ten years. eTh limb salvage rate was 98% at vfi e and 10 years. We conclude that articular deterioration and fracture were the most frequent mode of failure in proximal humeral osteoarticular reconstructions and allograft resorption in elbow reconstructions. eTh best functional score was observed in the intercalary humeral allograft. 1. Introduction the na fi l functional score compared to the anatomical site and the type of the reconstruction. Excisions of a bone tumor in the upper extremity may result in a large residual osseous defect and the loss of periarticular 2. Patients and Methods so-ft tissue stabilizers of the shoulder [ 1–10], elbow [11, 12], or wrist [13–15] with potentially deleterious effects on both From January 1990 to December 2008, we performed a function and viability of the limb. For these locations, there consecutive series of 72 patients with a musculoskeletal are different reconstructions options including prosthetic tumor from the upper limb who underwent reconstruction devices [3, 5–7], biological constructs either with autograsft with a massive allogra.ft Two patients were excluded due to a [5, 6]orallograsft [ 1–15], or the combination of allograft with lack of adequate followup data, leaving 70 cases for analysis. prosthesis [7–11]. Of the 70 reconstructions, 38 were osteoarticular allo- Reconstruction with a massive allograft is preferred in grafts, 23 were allogra-p ft rosthetic composites (APC), and 9 ourservice duetothe possibilityofobtaining supporting were humeral intercalary allografts. Of the 38 osteoarticular mechanical loads and the ability to attach host ligaments and reconstructions, 21 were of the proximal humerus (Figure 1), muscles to the grafts. 16 were of the distal radius (Figure 4), andone of thedistal eTh purposeofthisstudy wastoinvestigate thesurvival humerus. Of the 23 allograft-prosthetic composites, 16 were of allograft reconstructions in the medium to long term, to proximal humeral reconstructions (Figure 2), and 7 were determine factors associated with their failure, and to analyze elbow reconstructions (Figure 3). 2 Sarcoma Figure 1: Anteroposterior radiograph of an osteoarticular allograft Figure 3: Anteroposterior radiograph of an APC of the elbow aer ft of the proximal humerus aer ft 5 years of reconstruction. resection of the proximal ulna. Figure 2: Anteroposterior radiograph of an APC of the proximal Figure 4: Anteroposterior radiograph 16 years aer ft distal radius humerus showing adequate union of the junction. osteoarticular reconstruction. Although degenerative changes are evident, the patient is asymptomatic with excellent function. Demographic data, diagnosis, site of the neoplasm, oper- ations performed, surgical complications, outcomes after surgery, date of last followup evaluation, and local recurrence 1 month aer ft the operation, we obtained plain radiographs were reviewed for all patients. at every visit. We performed functional evaluation using the There were 38 men and 32 women in the study group. eTh revised 30-point functional classification system established mean age at presentation was 32 years (range 4–71 years). by the MSTS [16], which assessed pain, function, emotional eTh most common indication for reconstruction was chon- acceptance, hand positioning, dexterity, and lifting ability. drosarcoma in 18 patients, followed by osteosarcoma in 15, Each variable was assessed on a 5-point scale. Function giant cell tumors in 15, metastasis in 6, Ewing sarcoma in was compared according the anatomical site and the type 5, chondroblastoma in 2, and others types of tumors in the of reconstruction performed. Surgical complications were remaining 9 patients. eTh mean duration of followup was 5 defined according to the Clavien-Dindo classification [ 17] years for patients who survived the original disease (range 1– that separates complications in vfi e grades: Grade I, any 20 years). deviation from the normal postoperative course without the Postoperatively, patients were seen at 1 week, 2 weeks, 1 need for pharmacologic treatment or surgical, endoscopic, month, 2 months, 3 months, and then every 3 months there- and radiographic interventions, with acceptable therapeutic after until 2 years, after which we met annually. Beginning regimens including drugs, such as antiemetics, antipyretics, Sarcoma 3 1 1 0.8 0.8 0.6 0.6 0.4 0.4 0.2 0.2 0 0 0 50 100 150 200 250 0 50 100 150 200 250 Months of followup Months of followup Survival function Survival function Censored Censored Figure 5: Allograft survival. Figure 6: Articular surface survival. analgesics, diuretics, electrolytes, and physiotherapy; Grade infections, 5 fractures, 5 resorptions, and 3 nonunions. How- II, complication requiring pharmacologic treatment with ever, only in 16 patients (23%) the allograft was removed (4 drugs other than those allowed for Grade I complications; local recurrences, 5 resorptions, 2 infections, and 5 fractures) Grade III, complication requiring surgical, endoscopic, or (Table 1). In 6 patients the allograft was not removed (3 local radiographic intervention; Grade IV, life-threatening compli- recurrencesinsoft tissueand the3nonunions). cation; and Grade V, death of a patient. We analyzed only Seven patients had local recurrences. Three recurrences Grades III, IV, and V complications in this series. were in the soft tissue and were resected with wide margins; in We considered an allograft to have failed when it was these three cases the reconstructions were not revised, so the removed through either a revision procedure or an amputa- allograft reconstruction was not affected. In four patients the tion, and in osteoarticular reconstructions, we considered a allograft was compromised by the local recurrence. In these jointtohavefailedwhenthe allograft wasnot removed, but fourcasesthegraftwasremovedwiththelocalrecurrenceand symptomatic degeneration of the joint was present at the last only two of them were reconstructed. One was reconstructed followup. with a new allograft (distal radius) and the other with a proximal humerus endoprosthesis. eTh remaining two eTh ratesofsurvivalofthe allogra,t ft he limb,and the patients were treated with a resection arthroplasty and with joint surface were estimated with the use of the Kaplan-Meier an amputation (both of them located in the humerus). method, starting on the date of the operation and ending on the date of removal, amputation, or the latest followup. Two patients had an acute deep infection, in which Cox regression analysis was done to determine whether age, theallograftwas removed, andatemporarycementspacer gender, diagnosis, type, and site of the reconstructions were with antibiotics was implanted. After 6 weeks of intravenous independent prognostic factors. eTh log-rank test was used antibiotics and another 6 weeks of oral antibiotics, we reim- to compare the survivorship curves. A𝑃 value of<0.05 was planted another allograft in one patient (wrist arthrodesis), considered to be significant. and the other patient was reconstructed with proximal humeral prosthesis. Five patients sueff r an allograft fracture, and all occurred 3. Results in proximal humeral osteoarticular reconstructions. All pa- Allograft survival ( Figure 5)atfive yearswas 79%(CI95%: tients required a second operation, including a second allo- 68%–90%) and 69% (CI95%: 55%–83%) at ten years for graft reconstruction with an APC in 3 patients, a second failurefromany causeasthe endpoint (Figure 1). The limb osteoarticular allograft in one, and a cement spacer in the survival rate was 98% at five and 10 years (CI95%: 94%– remaining patient. 100%). Five patients had allograft resorptions, all of them We identified 22 patients with complications requiring a occurred after an elbow reconstruction (four APCs and one second surgery (32%), including 7 local recurrences, two deep osteoarticular allograft). Of the failed elbow reconstructions, Cumulative survival Cumulative survival 4 Sarcoma Table 1: Allograft complications according the different types of reconstructions. Reconstruction Local recurrence Infection Fracture Resorption Nonunion Total (%) PHOA 2 — 5 — — 33% PHAPC 1 1 — — 2 25% HIA 1 — — — — 11% ER 1 — — 5 — 75% DROA 2 1 — — 1 25% PHOA: proximal humerus osteoarticular allogra;ft PHAPC: proximal humerus allograft prosthetic composite, HIA: humeral intercalary allogra;ft ER: e lbow reconstructions; DROA: distal radius osteoarticular allograft. Table 2: Mean MSTS functional results comparison of different types of reconstructions. Reconstruction Pain Function Emotional acceptance Hand positioning Dexterity Lifting ability Total PHOA 4 3 4 3 5 4 23 PHAPC 4 4 5 3 5 4 25 HIA 5 5 5 5 5 5 30 ER 3 4 4 4 5 4 24 DROA 4 4 5 5 5 5 28 PHOA: proximal humerus osteoarticular allogra;ft PHAPC: proximal humerus allograft prosthetic composite, HIA: humeral intercalary allogra;ft ER: e lbow reconstructions; DROA: distal radius osteoarticular allograft. two were converted to an elbow endoprosthesis, two had a the anatomic location of the reconstructions. Despite these resection arthroplasty, and one had a cement spacer. limitations, we believe that this series is one of the largest eTh three patients who underwent nonunion were treated series reported in the literature, and our results may provide with autologous bone graft and a new plate, without revision some trends in the treatment of massive bone defects in the of the reconstruction. upper limb. The articular surface survival ( Figure 6)ofthe group Regarding anatomical site, most publications are related of patients treated with an osteoarticular allograft was 90% to the proximal humerus. Osteoarticular allografts are used (CI95%: 79%–100%) at vfi e years and 54% (CI95%: 39%–69%) less frequently than in the lower extremity, but there are at ten years (Figure 2). All symptomatic articular deteriora- reports regarding this type of reconstruction in the proxi- tions occurred in the proximal humeral reconstructions, and mal humerus. Although some authors reported satisfactory none of them required revision because of this event. results with osteoarticular allograsft of the proximal humerus The only independent prognostic factors that were found [1] and survival rates of 78% at five years [ 2], recent reports to be significant on Cox regression analysis, with revision for suggest that better or at least similar results are obtained with any cause as the end point, were the gender of the patient allograft prosthesis composite and endoprosthesis recon- (more frequent in males:𝑃=0.02 ). structions regarding reconstruction survival and complica- For the patients who retained the reconstruction (54 tions [3–8]. Peabody [4] report that due to functional limita- cases), the mean MSTS functional score at last followup was tions as well as an extremely high rate of complications, they 26 of 30 (83%, range 18–30). eTh best mean functional score do not use osteoarticular allograsft to replace the proximal was observed in the intercalary humeral allograft group. aspect of the humerus. However, in a recent report [7]that (mean 30: 100%). The worst functional score was observed in analyzed 38 reconstructions of the proximal humerus the proximal humeral osteoarticular allograft group (23 points, endoprosthetic group presented the smallest complication range18–26), andthislower scorewas mainly related rate of 21%, compared to 40% in the allograft prosthesis com- with patients who had a significant articular deterioration positeand62%intheosteoarticularallograftgroup.However, (Table 2). in another report that analyzed 45 patients [5] reconstructed aer ft tumor resection of the proximal humerus they found that all limb-salvage procedures for the proximal humerus 4. Discussion were satisfactory for long-term survival, but none of the 26 disease-free surviving patients was able to abduct their In comparison with the lower extremity, there is relatively shoulder more than 90 , and only vfi e could achieve active paucity literature reporting survival and clinical results of abductionofmorethan30 .Thesurvivalratewas 83%for allograft reconstructionsaeft rexcisionofabone tumorofthe endoprosthesis, 79% in clavicula prohumero, and 75% in upper extremity. We include in this report all reconstructions osteoarticular allograft [ 5]. done in the upper extremity done in our unit. Reconstructions with APC in the proximal humerus eTh re aresomelimitations to this study. Thisisaretro- avoid problems of endoprosthesis or osteoarticular allograsft spective study with a relatively low number of patients and used alone [8–10]. In our series the higher amount of fractures followup. In addition, there are many variables related to Sarcoma 5 occurred at shoulder reconstructions with osteoarticular [2] H. DeGroot, D. Donati, M. D. Di Liddo, E. Gozzi, and M. Mercuri, “eTh use of cement in osteoarticular allografts for allografts, and these complications could be avoided with an proximal humeral bone tumors,” Clinical Orthopaedics and APC. In recent reports [8, 10] there are not differences regard- Related Research,no. 427, pp.190–197,2004. ing complications or survival with other methods. [3] M.I.O’Connor, F. H. Sim, andE.Y.S.Chao, “Limbsalvage for Although, reports on elbow reconstructions [11, 12]show- neoplasms of the shoulder girdle: intermediate reconstructive ed satisfactory functional outcome and survival, both reports and functional results,” Journal of Bone and Joint Surgery—Series included trauma and tumor patients. In our series, we found A, vol. 78, no. 12, pp. 1872–1888, 1996. high complication rate (75%) and a mean functional score of [4] P. J. Getty and T. D. Peabody, “Complications and functional 24 points. Five of seven patients’ present allograft resorption, outcomes of reconstruction with an osteoarticular allograft and this complication was noted in previous report [12]. aer ft intra-articular resection of the proximal aspect of the hum- All distal radius reconstructions in this series were osteo- erus,” Journal of Bone and Joint Surgery—Series A,vol.81, no.8, articular allografts. In our series we found low complication pp. 1138–1146, 1999. rate (19%) and high functional score (28 points). Similar [5] R.W.Rod ¨ l, G. Gosheger, C. Gebert, N. Lindner, T. Ozaki, and W. results are found in the literature [13–15]; however, all series Winkelmann, “Reconstruction of the proximal humerus aeft r include a high percent of patients with benign tumors (GCT). wide resection of tumours,” Journal of Bone and Joint Surgery— This could lead to less damage of soft-tissue structures and Series B,vol.84, no.7,pp. 1004–1008, 2002. better survival of thepatient andreconstruction. Although [6] Q. Yang, J. Li, Z. Yang, X. Li, and Z. Li, “Limb sparing surgery degenerative changes are reported [14], these are usually for bone tumours of the shoulder girdle: the oncological and asymptomatic (Figure 4). functional results,” International Orthopaedics,vol.34, no.6,pp. The lower complication rate and the best mean functional 869–875, 2010. scorewereobservedinthe intercalaryhumerus allograft [7] M. A. J. van de Sande, P. D. Dijkstra, and A. H. M. Taminiau, group. Van Isacker et al. [18] report in a series of forearm “Proximal humerus reconstruction aer ft tumour resection: allograft similar results, they found that intercalary allograft biological versus endoprosthetic reconstruction,” International had fewer complications than osteoarticular allografts, and Orthopaedics, vol. 35, no. 9, pp. 1375–1380, 2011. they had a better functional MSTS score. [8] A. Abdeen, B. H. Hoang, E. A. Athanasian, C. D. Morris, P. J. Boland, and J. H. Healey, “Allograft-prosthesis composite re- construction of the proximal part of the humerus. Functional 5. Summary outcome and survivorship,” Journal of Bone and Joint Surgery— Series A,vol.91, no.10, pp.2406–2415,2009. This study showed that allograft reconstruction aeft r a [9] A.W.Black,R.M.Szabo,and R. M. Titelman,“Treatment tumor resection of the upper limb may be durable, with a of malignant tumors of the proximal humerus with allograft- 69% survival rate at ten years. Despite the 32% incidence of prosthesis composite reconstruction,” Journal of Shoulder and complications, only 16 patients (23%) required an allograft Elbow Surgery,vol.16, no.5,pp. 525–533, 2007. removal and were considered as failures. We conclude that [10] P. Ruggieri, A. F. Mavrogenis, G. Guerra, and M. Mercuri, “Pre- articular deterioration and fracture were the most frequent liminary results aer ft reconstruction of bony defects of the prox- mode of failure in shoulder reconstructions and allograft imal humerus with an allograft-resurfacing composite,” Journal resorption in elbow reconstructions. eTh humeral intercalary of Bone and Joint Surgery—Series B,vol.93, no.8,pp. 1098–1103, allograsft had the lesser complication rate and the best functional score. [11] F. D. Kharrazi, B. T. Busfield, D. S. Khorshad, F. J. Hornicek, and H. J. Mankin, “Osteoarticular and total elbow allograft Conflict of Interests reconstruction with severe bone loss,” Clinical Orthopaedics and Related Research,vol.466,no. 1, pp.205–209,2008. Each author certifies that he or she has no commercial asso- [12] K. L. Weber, P. P. Lin, and A. W. Yasko, “Complex segmental ciations (e.g., consultancies, stock ownership, equity interest, elbow reconstruction aeft r tumor resection,” Clinical Ortho- patent/licensing arrangements, etc.) that might pose a con- paedics and Related Research,no. 415, pp.31–44,2003. flict of interests in connection with the submitted paper. [13] M. S. Kocher, M. C. Gebhardt, and H. J. Mankin, “Reconstru- ction of the distal aspect of the radius with use of an osteoartic- ular allograft aeft r excision of a skeletal tumor,” Journal of Bone Disclosure and Joint Surgery—Series A, vol. 80, no. 3, pp. 407–419, 1998. Each author certiefi s that his institution has approved the [14] G. Bianchi, D. Donati, E. L. Staals, and M. Mercuri, “Osteoar- reporting of this study, and that all investigations were con- ticular allograft reconstruction of the distal radius aer ft bone ducted in conformity with ethical principles of research. tumour resection,” Journal of Hand Surgery,vol.30, no.4,pp. 369–373, 2005. [15] R. M. Szabo, K. A. Anderson, and J. L. Chen, “Functional out- References come of en bloc excision and osteoarticular allograft replace- ment with the Sauve-Kapandji procedure for Campanacci grade [1] M. C. Gebhardt, Y. F. Roth, and H. J. Mankin, “Osteoarticular 3 giant-cell tumor of the distal radius,” Journal of Hand Surgery, allografts for reconstruction in the proximal part of the hu- vol. 31, no. 8, pp. 1340–1348, 2006. merus aeft r excision of a musculoskeletal tumor,” Journal of Bone and Joint Surgery—Series A,vol.72, no.3,pp. 334–345, [16] W. F. Enneking, W. Dunham, M. C. Gebhardt, M. Malawar, 1990. and D. J. Pritchard, “A system for the functional evaluation of 6 Sarcoma reconstructive procedures aer ft surgical treatment of tumors of the musculoskeletal system,” Clinical Orthopaedics and Related Research, no. 286, pp. 241–246, 1993. [17] P. A. Clavien, J. Barkun, M. L. De Oliveira et al., “eTh clavien- dindo classification of surgical complications: vfi e-year experi- ence,” Annals of Surgery,vol.250,no. 2, pp.187–196,2009. [18] T. van Isacker, O. Barbier, A. Traore, O. Cornu, F. Mazzeo, and C. Delloye, “Forearm reconstruction with bone allograft following tumor excision: a series of 10 patients with a mean follow-up of 10 years,” Orthopaedics and Traumatology,vol.97, no.8,pp. 793–799, 2011. MEDIATORS of INFLAMMATION The Scientific Gastroenterology Journal of World Journal Research and Practice Diabetes Research Disease Markers Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 International Journal of Journal of Immunology Research Endocrinology Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Submit your manuscripts at http://www.hindawi.com BioMed PPAR Research Research International Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Journal of Obesity Evidence-Based Journal of Journal of Stem Cells Complementary and Ophthalmology International Alternative Medicine Oncology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 Parkinson’s Disease Computational and Behavioural Mathematical Methods AIDS Oxidative Medicine and in Medicine Research and Treatment Cellular Longevity Neurology Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation Hindawi Publishing Corporation http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014 http://www.hindawi.com Volume 2014

Journal

SarcomaHindawi Publishing Corporation

Published: Feb 14, 2013

There are no references for this article.